Transcript

Norman Swan: Could a tummy tuck, abdominoplasty, cure back pain and urinary incontinence? That's what a group of plastic surgeons claim to have found in a recent study. The lead author is Alastair Taylor, a plastic surgeon who came into our Canberra studio this morning.

Alastair Taylor: Thank you Norman.

Norman Swan: I mean, this seems really weird.

Alastair Taylor: In what way?

Norman Swan: Well, why would a tummy tuck improve urinary continence and low back pain? Is this just an accidental finding?

Alastair Taylor: Well no, we've known this for some time, that both back pain and urinary incontinence can be improved by doing an abdominoplasty in the post-pregnancy population. The study was done really to cement these findings and whether there were any other mitigating factors that we could identify.

Norman Swan: Let's just describe an abdominoplasty. Is it simply a tummy tuck, you're removing loose skin on the abdomen?

Alastair Taylor: Well, the skin is the least important part of the operation. The most important part is sewing the muscles back together again, because when you are pregnant your muscles split apart at the front. The two strap-like rectus muscles that run down the centre of the abdomen are normally separated by a distance of maybe 3 or 4 millimetres, by a bit of hard, fibrous material. And pregnancy hormones melt fascia and make it more pliable so the baby can be accommodated growing in the womb, and that's supposed to snap back together afterwards, after the pregnancy is done, but sometimes the fascia gets stretched too much and can't go back again, so you are left with this latent gap in between the rectus muscles. That's okay at rest, but the trouble is that attached to the lateral border of the rectus are the obliques, and they tend to pull the rectus apart when you stand up or walk around or strain or do whatever, and that means that the anterior part of the abdomen is never stable. And it's that instability which gets transferred in the facia around the abdomen and into the floor of the pelvis as well that causes these problems with back pain and incontinence.

Norman Swan: What did you do in this study?

Alastair Taylor: Firstly I needed numbers because I only do 50 or 60 of these patients a year, and we needed to get much larger numbers to get statistical significance. So I recruited eight other plastic surgeons to contribute cases, and we used validated questionnaires before the operation for both incontinence and back pain, and then at six weeks afterwards and at six months afterwards.

Norman Swan: And the kind of incontinence was stress incontinence?

Alastair Taylor: Generally yes.

Norman Swan: When plastic surgeons do abdominoplasties, they also often do liposuction. Was liposuction done here as well?

Alastair Taylor: The one thing that was similar in all the abdominoplasties that were done in the study was the muscles were repaired in the centre line. And depending on the weight of the patient, there's a certain amount of liposuction done. The heavier people of course got more and if the thinner people got less. But everybody had all the skin excised from pubis to above their umbilicus, but everybody had the muscle repair.

Norman Swan: This was not a randomised trial, you just basically put 214 people through the study to see what happened to their incontinence and their back pain.

Alastair Taylor: That's right.

Norman Swan: Were the symptoms independently assessed, or the plastic surgeon did it for him or herself?

Alastair Taylor: No, they filled in the questionnaire and we took it at their word.

Norman Swan: What did you find?

Alastair Taylor: Post-operatively we found at six weeks that the abdo scorer had gone down to 8% disability from 21%, and from an incontinence score of 6 down to 1.6. And at six months, the back pain score fell further to 3%, and the incontinence stayed at 1.6.

Norman Swan: That's an average, which doesn't mean that every woman was helped.

Alastair Taylor: No one got worse.

Norman Swan: You're a glass half full kind of guy aren't you Alastair!

Alastair Taylor: No, I think that's an important point to make. There were situations that the six-week people still had more back pain than they had before the operation because they were still recovering, it's a big operation, it's four hours' worth of work. But by six months they had all settled down and there were probably two or three that stayed at their pre-levels but everyone else improved.

Norman Swan: And did they all have the same type of rehabilitation afterwards, because that could have influenced the results too.

Alastair Taylor: In my practice we have a physio and an osteopath that come round and help people become more upright. Because to get the abdomen back together again after you've cut out that amount of skin you've actually got to break the table and sit them up and sew them up in a sitting up position, and then when they start walking around afterwards they are walking around bent over double for a while. It takes a couple of weeks to straighten out fully, during which time the back pain usually gets worse rather than better. But once they are upright their outlook on life does improve and the world is a happier place.

Norman Swan: It's a pretty expensive, radical way to fix back pain and incontinence, isn't it?

Alastair Taylor: Well, how else do you fix back pain? It's an instability issue. The only way you can fix it is by doing this. And we want to make it more affordable for Australian women, which is why we are petitioning the government to bring abdominoplasty back on the Medicare schedule for women in these conditions. Medicare are in the process of reviewing most of their item numbers, and they have restricted abdominoplasty only to massive weight loss patients.

Norman Swan: A randomised trial would be good, wouldn't it, Alastair, because this is really just indicative data rather than proof.

Alastair Taylor: Yes but the patients served as their own controls. They weren't going to get better by any other means. They hadn't improved in that period of time since their pregnancy, so we didn't foresee them improving for any other reason.

Norman Swan: So as a plastic surgeon, how many of these have you got to do a year to be good at them. If you do get referred to a plastic surgeon for this operation, what's the question to ask? Because presumably you've got to do a certain number to be good at it.

Alastair Taylor: You have to have a passion for it too. There are some plastic surgeons that like doing breast surgery, I'm more of a body contouring kind of guy. So someone who is interested in it and has a passion for it is important.

Norman Swan: How much does it cost?

Alastair Taylor: Without health insurance it costs nearly $20,000, including GST. With an item number it would cost less than $10,000 out of pocket.

Norman Swan: Alastair, thanks for joining us.

Alastair Taylor: Sure.

Norman Swan: That body contouring kind of guy is Alastair Taylor who is a Canberra-based plastic surgeon.